What Your Therapist Doesn’t Know, Cont’d

Editor’s Note: This article previously appeared in a different format as part of The Atlantic’s Notes section, retired in 2021.

First, I want to say thank you for your thoughtful comments on my article “What Your Therapist Doesn’t Know,” on how data can make therapists more effective. I am honored that the article sparked so much thought.

Some readers raised questions about the applicability of metrics to therapy, and in particular whether FIT (feedback-informed treatment) can benefit therapy. These questions are valid. FIT is nothing close to a “cure-all.” Although a lot of studies have shown that FIT can benefit therapy, it is still very limited, and only works when therapists are invested in the process.  Like a thermometer, it only helps with some patients, and only when used correctly.  Its primary benefit is helping therapists identify their own blind-spots with clients at risk of deterioration.  That said, I think it is important for us to continue experimenting with new tools and methods to improve our work. This forthcoming book has excellent guidance on using FIT. This website by therapist and researcher Barry Duncan, also has lots of great resources on FIT, including studies on using FIT with children, families, and group therapy.

Many readers raised two important questions. First, they questioned whether some psychotherapy models are more effective than others. One commenter points to a study:

A pretty extensive 2013 meta-analysis was conducted and published in the Journal of Consulting and Clinical Psychology that showed that methods actually do matter concerning patient outcomes, as one would expect. The study showed that clients treated using specific methods had better patient outcomes than those that received treatment based solely around the therapeutic relationship.

When looking at patients six months after ending therapy, it appears “that added specific ingredients may contribute modestly to treatment outcomes.” In other words, at six months post-therapy, patients that received specific treatments generally fared better long-term than patients who received general treatment. This is hugely important because it suggests that the value of therapy goes beyond merely the relationship between therapist and patient, and that specific treatments DO matter.

There are over 500 models of therapy, and most major models have multiple studies showing they are more effective than other models, like a circular firing squad.  However, when many studies are all looked at together in meta-analyses, it is revealed that there are relatively minor or insignificant differences between models.  Note that individual studies (randomized clinical trials) are conducted under highly controlled conditions at clinical labs, which is generally not applicable to regular therapy in routine practice.  For example, no study to date has shown that training regular front-line therapists in “empirically supported treatments” improves client outcomes.  Rather, when outcome data of regular front-line therapists is examined, there is no difference in effectiveness between models.

On the other hand, many studies show great difference in effectiveness between therapists, regardless of the model they use. So the take-away message is to look for an effective therapist, regardless of whatever therapy model they use. These articles and books are good reading on this subject:

Second, some commenters questioned the impact of the therapeutic relationship on therapy outcomes. This is one of the most robust findings in psychotherapy research: The quality of the therapeutic relationship contributes more to the effectiveness of therapy than any other identified variable (10x more than the model of therapy). This paper is a good example, covering 200 research reports based on 190 independent data sources, and more than 14,000 treatments. This book, Psychotherapy Relationships That Work, also has an extensive summary.

A few commenters questioned whether psychologists, who have doctoral degrees, have better outcomes than other therapists who have masters-level degrees. While this makes intuitive sense, it has not been demonstrated in the research. In fact, studies such as this one routinely show no differences in effectiveness between therapists of different degrees.

Still, it’s important for therapists to build our own emotional wisdom, as this commenter mentioned:

I think FIT could be helpful to a therapist who is already empathetic and has some skills. However, this does not address the problem of therapists having their own insecurities and emotional reactions and working them out on the client. Much of the challenge of therapy is being able to recognize and differentiate between one’s own emotional response and the client’s actual needs and feelings. Without this skill, which is generally only obtained by getting some quality therapy for the therapist, no amount of feedback will be sufficient to create a real sense of safety for the client, because the client will always have the sense that saying the wrong thing will upset or disappoint the therapist. The fact that 70 percent of clients lie to protect their therapists probably says a lot more about the therapists than the clients.

I agree with this point. An excellent recent paper on this topic is here, and a great book on how therapists develop their work, based on data from a very large study, is available here.

Some readers are skeptical about the effectiveness of therapy or have had bad experiences from past therapy—and while research shows that therapy is generally effective for many people, not each therapist/client match is necessarily effective.  My outcome data is a good example: I help many of my clients, but not all. (You can see my outcome data here. ) Some of the clients I have been unable to help have found more success with other therapists. My personal experiences in therapy are similar: Some of my therapists have helped me a lot, some a little, and some not at all.  In this regard, we are no different than doctors or professionals of any other domain. I think this reader, a pastor, offers wise advice:

You should think about your therapist like you think about your housing. It’s really important, hard to find a right fit, and you should assume you need to look at multiple people before you find the one that’s right. It just makes it easier to move through it when you get a crappy therapist or have a bad personality match, rather than assuming the problem is you or therapy in general.

Thank you again to everyone for your insightful comments!